[104-10222-10040.pdf — page 71]
IMPORTANT.-The filing of this form will completely cancel any Designation of Beneficiary under the FederalEmployees' Group Life Insurance Act you may have previously filed. Be sure to name in this form all persons you wishto designate as beneficiaries of any group life and accidental death insurance payable under that act at your death.EXAMPLES OF DESIGNATIONSHow To DESIGNATE ONE BENEFICIARY| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Mary E. Brown                                                               | 214 Central Avenue, Muncie. Ind.          | Niece        | All                                  |How To DESIGNATE MORE THAN ONE BENEFICIARY| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Alice M. Long                                                               | 509 Canal Street, Red Bank, N. J.         | Aunt         | One-fourth                           || Joseph P. Brady                                                             | 360 Williams Street, Red Bank, N. J.      | Nephew       | One-fourth                           || Catherine L. Rowe                                                           | 792 Broadway, Whiting, Ind.               | Mother       | One-half                             |How To DESIGNATE A CONTINGENT BENEFICIARY| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || John M. Parrish, if living                                                  | 810 West 180th Street, New York, N. Y.    | Father       | All                                  || Otherwise to: Susan A. Parrish                                              | 810 West 180th Street, New York, N. Y.    | Sister       | All                                  |How To CANCEL A DESIGNATION OF BENEFICIARY THAT AMOUNT DUE WILL BE PAYABLE AS PROVIDED IN THE LAW| Type or print first name, middle initial, and last name of each beneficiary | Type or print address of each beneficiary | Relationship | Share to be paid to each beneficiary || --------------------------------------------------------------------------- | ----------------------------------------- | ------------ | ------------------------------------ || Cancel prior designations                                                   |                                           |              |                                      |*If no real estate exists to H. E. Brown or to Mrs. Julia H. Brown,same proportion that the shares to be paid to the several.